{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"JOHN   S ROBINSON","gend":0,"add":"216 85TH ST UNIT B","city":"VIRGINIA BEACH","state":"VA","zip":"23451-9998","dob":"1969-08-14","age":"","mstatus":"","insh":"8628343*01","cliId":"","pno":"757\/639-8269","cno":"757\/639-8269","email":"","ename":"","eno":"","pphy":"MOLLENKOPF, WILLIAM MD","ppno":"757\/352-2030","pcpadd":"1168 FIRST COLONIAL ROAD","pcpcity":"VIRGINIA BEACH","pcpstate":"VA","pcpzip":23454,"pcpcounty":"","pcpid":156215,"pcpname":"First Colonial Medical Associates","plan":"OHP","program":"ACA","lob":"Small Group","region":"TIDEWATER","aligned":"","ano":"757\/631-0015","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["D48.5","L81.4","Z12.11","Z86.010","D12.3","K62.1","D12.0","D12.2","D22.5","E78.5","Z00.00","Z12.5","D12.5","D12.7","D12.4","D12.6","K63.5","N20.0","Z80.42","E03.9","A60.00"],"date":["2021-03-24","2021-03-24","2021-04-19","2021-04-19","2021-04-19","2021-04-19","2021-04-19","2021-04-19","2020-01-09","2021-05-17","2021-05-10","2020-11-09","2020-02-17","2020-02-17","2020-02-17","2021-04-19","2021-05-17","2020-09-21","2020-11-16","2021-05-17","2020-11-16"],"priorHcc":["","","","","","","","","","","","","","","","","","","","",""]}},{"a":[]}]},{"t":"Covid Screening","q":[{"a":[]}]},{"t":"Self-Assessment and Social History","q":[{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Activities of Daily Living","q":[{"a":[]}]},{"t":"Medical History","q":[{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Family History","q":[{"a":[]}]},{"t":"Preventive Care","q":[{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Allergies \/ Medications","q":[{"a":[]},{"a":{"comment":"","sub":[["","00781518792","LEVOTHYROXIN","150MCG","90","Select","Select",""],["","65862042005","SMZ\/TMP","800-160","20","Select","Select",""],["","72305017530","EUTHYROX","175MCG","90","Select","Select",""],["","69543038810","KETOROLAC","10MG","-20","Select","Select",""],["","65862044830","VALACYCLOVIR","500MG","30","Select","Select",""],["","00603389032","HYDROCO\/APAP","5-325MG","15","Select","Select",""],["","00781518792","LEVOTHYROXIN ","150MCG","90","Select","Select",""],["","00603389032","HYDROCO\/APAP ","5-325MG","15","Select","Select",""],["","72305017530","EUTHYROX ","175MCG","90","Select","Select",""],["","69543038810","KETOROLAC ","10MG","-20","Select","Select",""],["","65862042005","SMZ\/TMP ","800-160","20","Select","Select",""],["","65862044830","VALACYCLOVIR ","500MG","30","Select","Select",""]]}},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Review of Systems and Diagnoses","q":[{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Pain","q":[{"a":[]}]},{"t":"Vital Signs","q":[{"a":[]},{"a":[]}]},{"t":"Exam Review","q":[{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Screenings Needed","q":[[["No","Select","","","","","Select","",""],["No","Select","","","","","Select","",""],["N\/A","Select","","","","","Select","",""],["Yes","Select","","","","","Select","",""],["N\/A","Select","","","","","Select","",""],["N\/A","Select","","","","","Select","",""],["N\/A","Select","","","","","Select","",""]]]},{"t":"Mini-Cog","q":[{"a":[]}]},{"t":"Home Safety & Personal Goals","q":[{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Active Problem Conditions","q":[{"a":[]}]},{"t":"Patient Summary","q":[{"a1":"","a2":"","a3":"","a4":"","a5":"","a6":"","a7":[],"a8":"","a9":"","a10":[],"a11":"","a12":""}]}]}